Colony of Thousand Oaks at Sidlee West

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:57AM. The LPA met with the Administrator Marisol Flamenco and the Licensee Rashita Aggarwal arrived shortly thereafter. Entrance interview conducted. Beginning at 10:21AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food and water. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Resident files and supplies were stored inaccessible in a cabinet near the refrigerator. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had an electric fireplace that is not utilized. Required postings were located on the entryway wall and dining area. The facility maintained a comfortable temperature throughout the visit. The facility had a laundry room with machines in good condition. Laundry detergent and facility cleaning supplies were stored locked in a cabinet located in the laundry room. There was a garage that contained general storage and remained locked. Report Continued on LIC 809-C The LPA observed a built-in wall with two (2) rooms in the garage. One (1) room was utilized by Staff and the second room contained storage. The Licensee stated they added the wall and rooms earlier this year and did not obtain building permits or notify Community Care Licensing (CCL). BEDROOMS/RESTROOMS: Inside the home, there were nine (9) bedrooms; six (6) private resident bedrooms and three (3) locked staff bedrooms. Bedrooms #1, #3, #5, and #6 have direct exits to the outside with all bedrooms cleared for a total of six (6) bedridden residents. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinets. The facility’s floor plan provided to CCL indicated two (2) staff rooms; however, during the visit the LPA observed a total of four (4) staff rooms. The Licensee stated that the bedrooms existed prior to the change of ownership, and the floor plans should be accurate. CCL’s floor plan and the posted floor plans around the facility were not accurate/updated. Additionally, the facility did not obtain fire clearance for the additional staff rooms. There were four (4) total restrooms in the facility: two (2) private resident restrooms and two (2) common area restrooms. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 105.8 degrees F and 106.7 degrees F. OUTDOOR AREA: The surrounding grounds had a shaded patio area equipped with furniture in good condition for residents’ use. There was one (1) emergency exit located on one side of the facility with a self-latching mechanism. The opposing side of the property also had a self-latching gate. The side exits and passageways were not free of obstruction and contained furniture which included mattresses, bed frames, dressers, and buckets. The Licensee’s maintenance men arrived and cleared the passageways during the visit. The LPA also observed three (3) window screens in disrepair with rips and one (1) window did not have a screen. Report Continued on LIC 809-C RECORDS: Record review began at 10:53AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Two (2) out of six (6) staff reviewed were not associated to the facility. The Licensee stated that one (1) staff worked at the facility for one (1) month and has primarily worked at their subsequent facility. The LPA explained that all staff and/or volunteers are required to be fingerprint cleared and associated with the facility prior to working at the facility. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 09/27/2025. Smoke and carbon monoxide detectors were tested at 12:43PM and were operational. Fire extinguishers were observed throughout the facility and was last serviced on 10/04/2025. MEDICATIONS: Medication review began at 12:46PM. Medications were centrally stored and kept inaccessible in a locked closet located in the hallway. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties. Report Continued on LIC 809-C An immediate civil penalty of $100 per day for a maximum of five (5) days in the amount of $1000 for employment without a criminal record clearance, exemption, or transfer was issued (Refer to LIC 421BG). The Licensee understands that continued employment without clearance may result in additional civil penalties. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Oct 28, 2025

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff is interfering with a resident's visitations

Licensing Program Analyst (LPA) Erica Mosley conducted a subsequent complaint visit to investigate the above allegation. Upon arrival approx. at 9:45 a.m., LPA Mosley was greeted by the Administrator, Eleanor Jimenez as we arrived to the facility at the same time. Licensee Representative/ Administrator Dr. Rashita Aggarwal arrived during the visit. The reason for the visit was explained. Entrance interview conducted. On 07/24/2025, the Department received a complaint regarding the following allegation, Staff is interfering with a resident's visitations. During today’s visit starting at 9:50 a.m LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During todays visit the LPA conducted a medication audit for Resident #1 (R1) at 10:09 a.m., A wellness check and a brief interview at 11:18 a.m. and obtained copies of pertinent documents relevant to the investigation. LPA reviewed all of R1's medications starting at 10:09 a.m. Medications are centrally stored in a locked closet located in the hallway adjacent to the dining room. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be given according to the physician order via G-Tube as prescribed and documented on the centrally stored medication and destruction records. No errors observed. On 07/25/2025 starting at 11 a.m. LPA conducted eight (8) in-person interviews, with three (3) residents including R1, two (2) family visitors, four (4) staff including the Licensee Representative, and Administrator, attempted four (4) telephonic interviews, at 12:39 p.m. conducted a file review for R1 and obtained copies of pertinent documents relevant to the investigation. On 07/30/2025 LPA conducted two (2) telephonic interviews at 3:15 p.m. with R1’s conservator and at 2:41 p.m. with R1’s son. On the allegation Staff is interfering with a resident's visitations it is the concern of the Reporting Party (RP) that the facility staff are limiting R1’s telephone calls by denying access to R1’s son. To investigate this complaint, LPA conducted eight (8) in-person interviews, with three (3) residents including Resident #1 (R1), two (2) family visitors, four (4) staff including the Licensee Representative, and Administrator, attempted four (4) telephonic interviews, at 12:39 p.m. conducted a file review for R1 and obtained copies of pertinent documents relevant to the investigation. On 07/30/2025 LPA conducted two (2) telephonic interviews at 3:15 p.m. with R1’s conservator and at 2:41 p.m. with R1’s son. Resident interviews including R1 indicated that residents were unable to provide information due to limited cognitive awareness. LPA observation revealed that during the initial visit conducted on 07/25/2025 LPA made three (3) separate attempts at 11:52 a.m., 12:31 p.m. and at 1:31 p.m. to speak / interview R1. Two (2) of the three (3) attempts R1 was sleeping. At 12:46 p.m. the LPA observed R1 to receive a phone call from their son and staff assisted with the phone call. Interviews with two (2) family members / visitors revealed that they visit on a daily basis and have not had any concerns or issues with visitation. The staff and Administration team have not restricted visits and are very flexible with visiting hours. Visitors primarily conducted in person visits and have yet to attempt or conduct a telephonic visit / phone call. It was noted that, due to limited cognitive awareness, they believe the resident would be unable to understand the components of accepting a phone call or handling the phone in general. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099... Furthermore, it was observed that when the facility receives a phone call, staff answer the call and bring the phone to R1. While the caller's identity remains unknown, they have witnessed staff deliver the phone to R1. Interviews with four (4) staff including the Licensee Representative, and Administrator revealed that they ensure compliance, emphasizing adherence to resident’s personal rights. R1 receives daily phone calls from their son. When R1’s son calls the staff check if R1 is awake before taking the phone to R1. If awake, R1 may engage in brief communication, usually once or twice a day but there are times when R1 does not respond. R1’s son will typically call four (4) to five (5) times per day. R1 has occasionally declined to speak with son, either by handing the phone back or verbally indicating they do not wish to speak. Staff consistently assist with incoming phone calls and have never failed to assist with phone calls. Additionally, staff make efforts to support phone calls unless there is an emergency, or they are momentarily occupied. In such cases, callers are informed and asked to call back. Interviews with R1’s conservator revealed that Based on available notes, the agency has not encountered any issues contacting or visiting R1, nor have they experienced resistance from facility staff. Interview with R1’s son revealed that they shared concerns about R1’s condition, stating that during a phone call earlier that day, R1 was coughing and seemed disoriented. It was noted that during recent conversations, R1 appeared disengaged and had difficulty speaking, often coughing. Additionally, it was noted by staff to the son that R1 sleeps approximately half of the time. Out of 5–6 attempted calls, staff were only able to assist with 2–3 calls; during the remaining calls, staff stated that R1 was asleep. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff is interfering with a resident's visitations is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 29-AS-20250724143004

Type of visit: Case Management - Deficiencies

At approximately 9:55am Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit due to a deficiency observed during a complaint investigation. LPA and Administrator, Eleanor Jimenez conducted a medication audit at 10:09 a.m. Medications are centrally stored in a locked closet located in the hallway adjacent to the dining room. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. Medications were pre-sorted for three (3) days in advance. Staff was made aware that medication cannot be pre-sorted and made aware of the potential health and safety risk. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Aug 29, 2025

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in five (5) out of five (5) residents medications were pre-sorted which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: Administrator will provide a statement to CCL by the indicated date confirming their understanding of this regulation and their intent to abide by it. Administrator will speak to staff about the importance of not pre-sorting medications along with providing a signed statement with all staff.

Allegation investigated: Staff admitted a resident with a prohibited health condition

Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival approx at 10:45 a.m., LPA Mosley was greeted by Staff who called the Administrator to inform them of the visit. The Administrator Eleanor Jimenez and Licensee Representative/ Administrator Dr. Rashita Aggarwal arrived shortly after and the reason for the visit was explained. Entrance interview conducted. On 07/24/2025, the Department received a complaint regarding the following allegation, Staff admitted a resident with a prohibited health condition. LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today’s visit, starting at 10:51 a.m. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, starting at 11 a.m. conducted eight (8) in-person interviews, with three (3) residents including Resident #1 (R1), two (2) family visitors, four (4) staff including the Licensee Representative, and Administrator, attempted four (4) telephonic interviews, at 12:39 p.m. conducted a file review for R1 and obtained copies of pertinent documents relevant to the investigation. On the allegation Staff admitted a resident with a prohibited health condition, it is the concern of the Reporting Party (RP) that the facility staff admitted R1 with a prohibited health condition of a gastrostomy tube (g-tube) and are unaware if the facility can accept or treat R1 with the g-tube. To investigate this complaint, LPA conducted four (4) in person interviews with the staff including the Licensee Representative, and Administrator, and conducted a file review on R1. Interview with the Licensee representative and Administrator revealed that R1 has been on Hospice since 01/17/2025 and submitted all the required documentation to licensing. R1 is seen 2-3 times a week by the hospice agency who handle and care for R1 g-tube. Licensee Representative also noted that they are licensed physician, an appropriately skilled professional who is available on site to monitor R1’s feeding and assess the insertion site on a daily basis, as they are regularly at the facility to monitor R1. Staff interviews revealed that the hospice agency is regularly at the facility ranging from 2-3 times a week monitoring R1’s g-tube. Staff also noted that the Licensee representative, Dr. Rashita Aggarwal is at the facility on a daily basis and monitors R1 focusing on the g-tube. File review revealed that R1 is receiving hospice services and have been on hospice since 01/17/2025. The agency is scheduled to have a minimum of 3 visits a week and handle R1’s plan of care including the g-tube. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff admitted a resident with a prohibited health condition is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided. *This report has been amended to remove confidential information*the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 29-AS-20250724143004

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: “Report is being amended and its contents removed as it is a duplicate of the same report issued on 07/25/2025.”

“Report is being amended and its contents removed as it is a duplicate of the same report issued on 07/25/2025.” Unsubstantiated (PAGE 2) Report continued from LIC 9099... “Report is being amended and its contents removed as it is a duplicate of the same report issued on 07/25/2025.”the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 29-AS-20250724143004

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 11:52AM to conduct an annual inspection. LPA initially met with facility staff. Licensee, new Administrator, and Facility Designee were contacted via telephone. All 3 (three) managers arrived shortly after the visit began. Entrance interview conducted. Beginning at 12:02PM, the LPA, along with facility management toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers were observed to be fully charged and recently serviced 10/04/2024. Hardwired combination smoke and carbon monoxide detectors and fire door were tested at 03:02PM. All were functional at the time of the visit. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. Fireplace was observed to be inaccessible to residents. All furnishings were observed in good condition. All required postings were observed in common areas. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer on the left hand side of the stove. Cleaning supplies are locked in an under-sink cabinet. The supply of perishable and nonperishable food is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food and water. LAUNDRY/GARAGE: The laundry area is located in the hallway to the right of the facility next to bedroom #1. Laundry detergent and chemicals are locked and stored inaccessible in the laundry room. The garage was observed locked and inaccessible to residents in care. The garage contained storage and a refrigerator/freezer containing extra food. Report Continued on LIC 809-C EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There is a gated pool that was observed to be locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south-side passageways, both gates have self-latching mechanisms. BEDROOMS: There are (8) eight bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff rooms. Both staff rooms are kept locked. Room #4, #6 do not have direct access to the outside. Lighting in the rooms appeared adequate. All resident rooms were observed and were furnished appropriately at the time of the visit. BATHROOMS: There is (1) half bath and (1) full bathroom in the hallway. There are two (2) additional private bathrooms for resident use; the half bathroom in the hallway is designated for staff and guests, the full bathroom in the hallway is designated for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured within the required range. FILES: Beginning at 12:28PM, LPA observed 6 (six) resident files for items including but not limited to physician's report, physician's orders, needs and service appraisals, and personal rights. All resident files were in order. LPA observed 4 (four) staff files for items including but not limited to health screening, TB test, criminal record clearance, and training records. All staff records were observed to be complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan and emergency disaster plan; both of which were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 09/16/2024. MEDICATIONS: Medications are stored in a locked cabinet in the hallway. The first aid supplies were complete, including a first aid manual. At 01:58PM, medications for 2 (two) residents were observed. Medications for both residents were observed to be properly stored and documented per regulation. INTERVIEWS: During today's visit, LPA conducted interviews with both staff and residents. No concerns were noted during interviews. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2024

Allegation investigated: Resident sustained a pressure injury while in care. Staff did not seek timely medical care for resident in care. Resident sustained unexplained head injury while in care. Resident in care was severely dehydrated while in care. Staff medicated resident with an unauthorized medication.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Urena met with and explained the reason for the visit. On 01/12/2024, the Department received a complaint alleging neglect, lack of care and supervision regarding Resident #1 (R1). The complaint alleged the facility, Colony of Thousand Oaks at Sidlee West Inc. neglected a pressure injury noted on R1, failed to seek timely medical attention, R1 sustained an unexplained head injury while in care, and noted R1 was severely dehydrated. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Johnny Canto. Continues on LIC 9099C... Unsubstantiated Pg. 2. On 01/16/2024, from 1:35pm to 2:55pm, Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced, initial 10-day complaint visit to the facility. LPA Campos met with Administrator Connie Roush and explained the reason for the visit. During the visit, the LPA conducted a facility tour at 1:35pm for any immediate health and safety hazards and none were observed, reviewed resident documents at 1:55pm, and obtained pertinent documents. The LPA determined that further investigation was needed and advised Administrator Connie Roush that the complaint was referred to the Department's Investigation Branch (IB) for further investigation. Investigator Canto and Investigator Jose Santana conducted interviews on 01/23/2024, from approximately 10:00am to 11:30am, with R1, the administrator, staff, and Resident #2 (R2). On 02/09/2024, at approximately 4:15pm, investigator Canto conducted an interview with R1’s resident representative; and on 02/21/2024, at approximately 3:15pm, with R1’s home health nurse. In addition, the investigator reviewed Los Robles Regional Medical Center medical records and facility file documents related to R1. According to R1’s physician’s report, dated 08/16/2023, the primary diagnosis is listed as dementia, anxiety, and chronic back pain, requires assistance with medications, with a secondary diagnosis of osteoporosis, and GERD Gastroesophageal reflux disease. R1 has no contagious diseases, has a history of skin breakdown, bowel impairment, and bladder impairment disoriented, has sundowning behavior, and can follow instructions and communicate needs. The resident appraisal report, dated 08/28/2023, noted R1 has no dietary limitations, can ambulate with a walker, requires a lot of redirections and prompting, can sometimes be forgetful, has a history of shortness of breath, loves to do puzzles, and loves to draw. R1 can walk without physical assistance. Continues on LIC 9099C... Pg. 3. The Los Robles Regional Medical Center records revealed that on 01/10/2024, at approximately 8:21am, R1 was admitted to the hospital via ambulance. The chief complaint was listed as an unwitnessed fall. Patient with dementia, a history of agitation, multiple psychiatric medications, and hypertension, presenting after an unwitnessed fall from their facility. The patient has bruising and hematoma on head, was complaining of lower back pain. Patient appears to be at their neurological baseline, able to state name, but unable to state the date of birth or location. Stable to follow some simple commands. Patient has some swelling on the shoulder. X-rays taken ruled out any acute fractures. It was noted that R1 was recently diagnosed COVID-positive and being treated. R1 was discharged back to the facility on 01/12/2024. On the allegation “Neglect Lack of Care & Supervision – Resident sustained a pressure injury while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. R1 was subsequently admitted to Los Robles Regional Medical Center. Interviews were conducted with R1, the facility administrator, the facility staff, R1’s resident representative and R1’s home health nurse. R1’s resident representative was made aware of the fall by the facility, has never been informed of any pressure injury to R1 while residing at the facility, and believes the facility took appropriate measures when they found R1 on the ground in R1’s room. R1’s resident representative had no concerns as to the quality-of-care R1 receives at the facility. The medical records were reviewed and noted R1’s skin was intact, normal in color, with no rash, and warm and dry. R1’s home health nurse stated R1 had a pressure injury to their heel which was healing appropriately. The Department found no evidence that R1 was admitted to Los Robles Medical Regional Center with a pressure injury. Based on the medical records and interviews conducted, the Department concluded that there was insufficient evidence to substantiate the allegation. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident sustained a pressure injury while in care” is deemed Unsubstantiated at this time. Continues on LIC 9099C... Pg.4. On the allegation “Neglect Lack of Care & Supervision – The facility failed to provide timely medical attention for resident while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. The medical records were requested and reviewed. The facility staff conducted round checks at approximately 6:00am on 01/10/2024 and noted R1 was still in bed, upon completion of their second-round checks at 7:30am, the facility staff discovered R1 on the ground in their bedroom. The facility staff assisted R1 to the couch and assessed R1. The facility staff contacted the facility administrator and were instructed to contact 911 for transfer. Medical records noted that at approximately 7:55am the ambulance arrived at the facility and transferred R1 to Los Robles Regional Medical Center. The Department found no evidence that the facility failed to seek timely medical attention for R1. Based on the medical records and interviews conducted, the Department concluded that there was insufficient evidence to substantiate the allegation. Therefore, the allegation “Neglect Lack of Care & Supervision – The facility failed to provide timely medical attention to resident while in care” is deemed Unsubstantiated at this time. On the allegation “Neglect Lack of Care & Supervision – Resident sustained an unexplained head injury while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. Medical records were requested and reviewed. The facility staff conducted round checks at approximately 6:00am on 01/10/2024 and noted R1 was still in bed, upon completion of their second-round checks at 7:30am, the facility staff discovered R1 on the ground in R1’s bedroom. The facility staff assisted R1 to the couch, assessed R1, and noted a discoloration to R1’s temporal/head area. The facility staff photographed and documented their findings. The facility staff contacted the facility administrator and were instructed to contact 911 for transfer. Medical records noted that at approximately 7:55am the ambulance arrived at the facility and transferred R1 to Los Robles Regional Medical Center. While R1 did sustain an unwitnessed fall at the facility which resulted in a head injury, the Department found no evidence that the facility neglected the care of R1. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident sustained an unexplained head injury while in care” is deemed Unsubstantiated at this time. Continues on LIC 9099C... Pg. 5. On the allegation “Neglect Lack of Care & Supervision – Resident was noted to be severely dehydrated while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. Medical records were requested and reviewed. Upon discovering R1 on the floor of their bedroom, the facility staff contacted 911. R1 was transferred to Los Robles Regional Medical Center. Medical records noted that upon admission, at 8:27am, R1’s sodium level was 134 (Baseline 136-145 mmol/L). R1’s potassium level was noted at 4.8 (baseline 3.6-5.1 mmol/L). R1 was given fluids but was not noted as having severe dehydration. The Department found no evidence that the facility neglected the care of R1 leading to severe dehydration. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident was noted to be severely dehydrated while in care” is deemed Unsubstantiated at this time. On the allegation of “Staff medicated resident with an unauthorized medication -Resident has been over-medicated with antipsychotic medications without proper authority”. On 01/16/2024, LPA Campos obtained a list of medications created by Los Robles Hospital and was collected as part of the pertinent records to be reviewed for the allegation above. The list of medications was printed on 01/12/2024. On 06/20/2024, LPA Urena conducted a review and audit of the Centrally Stored Medication and Destruction Record Form (LIC 622) and obtained additional records pertaining to the allegation. Review of the LIC 622 revealed that the medications listed on the LIC 622 are prescribed by R1's attending physician. Therefore, the allegation that “Resident has been over-medicated with antipsychotic medications without proper authority”-is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 29-AS-20240112155611

Allegation investigated: Staff isolates resident. Staff are not meeting resident overall needs. Staff do not provide activities for resident.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation findings. Upon arrival LPA met with Connie Roush and explained the reason for the visit. Entrance interview conducted. On 04/17/2024, Community Care Licensing Division received the above complaint allegations. It was alleged that resident #1 is isolated in this facility moaning and groaning for hours every day with very little social interaction, no physical therapy services and does not get to go outdoors or provided with any activities. It was also mentioned that resident #1 is not provided a higher quality of care as well as a higher quality of living and current medications need to be reviewed by a outside skilled professional and not the facility owner who is a physician or any associate of the facility owner. Investigation consist of interview with the facility owner, administrator, staff and residents on 04/18/2024; review of resident #1’s records, and interview with potential witnesses on 05/18/204. (Continue to LIC9099c) Unsubstantiated Following is a summary of the allegations and investigation findings: Regarding allegation “Staff isolates resident” – Information was provided that resident #1 is kept isolated in the facility and does not get to go outdoors. Owner of facility, administrator and staff denied the allegation and stated that when the weather is nice residents are taken out to the backyard and also if resident preferred, they would go out side around the block. According to staff residents are not isolated. Resident #1 was interviewed expressed being satisfied with staff and care. Resident #1 was asked if they feel isolated in the facility and resident expressed being satisfied with the facility staff and care provided. Three out of four residents who were able to communicate with LPA were interviewed and expressed that they feel safe at the facility and are satisfied with the care provided. Residents reported that they are not isolated and have not observed any other resident be isolated in the facility. Potential witnesses interviewed reported that they have never witness any resident to be isolated in the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to support the allegation of “Staff isolate resident.” Therefore, this allegation is deemed Unsubstantiated at this time. Regarding allegation “Staff are not meeting resident needs” – Information was provided that resident #1 is not provided a higher quality of care as well as a higher quality of living. According to reporting party resident #1 was scratching a lot and they are not sure if resident #1 is checked on or evaluated by a skilled professional. Also reporting party expressed that they feel that resident #1’s current medications prescribed are not good for resident #1 and felt that facility needs to have resident #1’s medications reviewed by an outside skilled professional and not the owner of the facility who is a physician or any other physician who is related to the owner. Interview with staff revealed that resident #1 is in no distress and does not require higher level of care and that they are able to meet resident #1’s needs. Owner and Administrator both stated that resident #1’s physician is approved by conservator and friend of resident #1’s. Resident #1 was interviewed and expressed being satisfied with the facility services and likes the facility and staff. Resident #1 did not look distressed or uneasy when observed at the facility during the initial visit on 4/18/2024 and subsequent visit on 05/08/2024. Resident #1’s medication record observed did not reveal any discrepancies and all medications recorded observed prescribed by the physician and reviewed last on 3/21/2024 by Dr. Kirti Talole. Three out of four residents interviewed did not reveal any unmet needs. Potential witnesses interviewed expressed being satisfied with the care services and feel that residents needs are met by care staff. Based on the information obtained during the investigation, the Department does not have sufficient evidence to support the allegation of “Staff are not meeting resident needs.” Therefore, this allegation is deemed Unsubstantiated at this time. Regarding allegation “Staff do not provide activities for resident” – Information was received that resident #1 is not offered any activities. Resident #1 was observed resting during LPA’s initial visit on 04/18/2024; LPA spoke with resident #1 once resident woke up. Resident #1 enjoys reading and painting/drawing. Staff and administrator shared some of resident #1’s drawings and stated that resident #1 also likes to read which resident does consistently during the day. Resident #1 acknowledged reading and painting at the facility. Resident expressed receiving great joy in reading and painting. Three out of four residents interviewed expressed that they offered several different activities however some residents choose to participate and other do not. Potential witnesses interviewed stated that facility do provide activities for residents. During the initial and subsequent visit on 04/18/2024 an 05/08/2024, LPA observed resident #1 reading and painting. Other residents were observed watching a movie/show. Based on the information obtained during the investigation, the Department does not have sufficient evidence to support the allegation of “Staff do not provide activities for resident.” Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 29-AS-20240417154252

Allegation investigated: Staff stuffed a rag into a resident's mouth while in care. Staff behavior poses as a risk to the residents.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation findings. Upon arrival LPA met with Connie Roush and explained the reason for the visit. Entrance interview conducted. On 05/01/2024, Community Care Licensing Division received the above complaint allegations. It was alleged that “Staff stuffed a rag into a resident's mouth while in care”. According to reporting party, Resident #1 doesn't speak much, if at all, but makes sounds and one of the staff took a rag and stuffed it into resident #1's mouth to keep resident quiet. It is unknown how often this happens. When reporting party expressed concern for resident #1, it was stated that “this is why everyone keeps leaving” and shared “they are mean to people here”. It was reported that this kind of behavior is inappropriate and poses as a risk to residents. Investigation consist of interview with the facility owner, administrator, staff, and residents on 05/08/2024; (continue to LIC 9099c). Unsubstantiated review of resident #1’s records, and interview with potential witnesses on 05/18/204. Following is a summary of the allegations and investigation findings: Regarding allegation, “Staff stuffed a rag into a resident's mouth while in care” and “Staff behavior poses as a risk to the residents”. Information was received that staff (name unknown) took a rag and stuffed it into resident #1's mouth to keep resident quiet. It is unknown how often this happens. I was also mentioned that staff are “mean to residents” which is a concern for residents and “this is why everyone keeps leaving”. Staff and licensee/administrator denied the allegation and stated that they are respectful to everyone and would not do such a thing. Staff denied ever being mean to any resident. Three out of the four resident who were able to communicate were interviewed and expressed being satisfied with the staff and care provided. Resident interviewed also denied the allegation and stated that they are not mistreated in any way and feel safe at the facility. Potential witnesses interviewed expressed that staff are good with the residents and they have not witnessed any staff mistreat or act in a mean way towards any of the residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to support the allegations of “Staff do not provide activities for resident” and “Staff behavior poses as a risk to the residents”. Therefore, this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 30, 2024 · control 29-AS-20240501231609

Allegation investigated: Staff are restricting a resident's visits with their family.

On Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegation listed above. The LPA met with the Licensee Rashita Aggarwal and Administrator Connie Roush and explained the reason for the visit. On 03/04/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day unannounced visit to investigate the allegation listed above. The LPA met with the Administrator Connie Roush and explained the reason for the visit. During today’s visit, the LPA, interviewed the Administrator at 11:00 a.m. and requested records pertinent to the investigation at 11:15 a.m. Continues on LIC 9099C... Substantiated Staff are restricting a resident's visits with their family. On the allegation of staff are restricting a resident’s (R1) visit with their family; the Reporting Party’s (RP) concern is that the staff violated the personal rights of the resident by not allowing the family members to visit with R1 privately. To investigate the allegation, the LPA reviewed records presented by the facility administrator pertaining to R1, and interviewed the Conservator on 03/07/2024, and the Case Worker on 03/07/2024. The interview with the administrator revealed that the Conservator had instructed the facility staff via telephone communication that R1 was allowed to have visitations from family members, however, only when the case worker was present. Furthermore, the administrator presented to the LPA a hand- written note created by the administrator, noting the statement of restricting visitations made by the Conservator with date and time of the telephone call. No additional documentation on the restriction was presented. The LPA reviewed the conservatorship court documents; and found that the court order does not reflect restrictions placed on the family visitations. Based on the information obtained through interviews and record review, there is sufficient evidence to support the allegation that staff violated the personal rights of the resident by not allowing the family members to visit with R1 privately. Therefore, the allegation that staff are restricting a resident's visits with their family, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 29-AS-20240227154958

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Apr 12, 2024

87468.1-Personal Rights (a)Residents in all residential... elderly shall have all of the following personal rights. (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice... This was not met by evidence: Based on observation, the administrator did not comply with the section cited above by stating that restrictions were place on visitations and were allowed by the facility administrator, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: POC: Administrator will submit a Statement of Understanding detailing the importance of Regulation 87468.1(a)(11) and submit by 04/12/2024.

Allegation investigated: Staff did not offer resident assistance for an extended period of time

Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial 10 day complaint visit. The LPA met with staff and Adminstirator Connie Roush and explained the reason for the visit. During today’s visit, the LPA, conducted a physical plant tour at 12:25 p.m., interviewed residents at 12:55 p.m., 1:03 p.m. and 1:06 p.m., interviewed staff at 1:10 p.m. and 1:15 p.m. Allegation: Staff did not offer resident assistance for an extended period of time It was alleged that staff leave Resident #1 (R1) unattended for extended periods of time and do not offer assistance, up to 2 hours. It was alleged that R1 was not checked on as the phone was left online and no one came to hang it up for up to 2 hours. Staff revealed that R1 uses the phone but does not know how to always hang it up and often leaves it online. **Contunued on LIC 9099-C** Unsubstantiated Staff do not interrupt R1 while they are on the phone and although it is known that R1 does not know how to hang up they will not interrupt to do so and will sometimes wait until the phone starts beeping. Interviews revealed that facility staff were responsible for tending to R1’s care needs both day and night. LPA observed R1 at the time of the visit and R1 did not appear distressed, unwell, or unattended. R1 confirmed that staff check on them throughout the day and it's plenty. R1 did not express any concerns with staff or their attentiveness to care. LPA observed staff doing continuous rounds to check on residents. Interviews with staff and residents confirmed that, staff regularly check in on the residents to ensure that their needs are met. Staff interviews revealed that residents are checked on continuously throughout the day at least every two hours to ensure that the residents needs are met timely. Interviews revealed that staff are responsive in meeting the needs of the residents and did not reveal any concerns regarding staff leaving them unattended for extended periods. Based on the information obtained, there is insufficient evidence to support the claim that staff did not offer resident assistance for an extended period of time. The allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 14, 2023 · control 29-AS-20231109124351

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 10:30 a.m. to conduct a pre-licensing inspection and conducted a subsequent visit unrelated to the pre-licensing inspection at this facility. LPA met with Administrator Connie Roush. This is a change of ownership application from Colony of Thousand Oaks at Sidlee West, Inc. (#565850181) to Colony of Thousand Oaks at Sidlee West Inc. (#565850370). The current census is six for (6) residents, the facility currently has five (5) residents. The fire clearance was granted on 07/21/2023; in which all rooms were cleared for bedridden residents. Component III was waived as the applicant currently operates three other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified. The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: There are (8) eight bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff rooms. Both staff rooms are kept locked. Room #4, #6 do not have direct access to the outside. Lighting in the rooms appeared adequate. (6) six out of (6) six private resident rooms and (2) staff rooms were set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There is (1) half bath and (1) full bathroom in the hallway. There are two (2) private bedroom bathrooms for resident use; the half bathroom in the hallway is designated for staff and guests, the full bathroom in the hallway is designated for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 105.0 – 108.6 degrees Fahrenheit. Continued on LIC 809-C. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hardwired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last serviced 11/8/2022. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted at the entrance area wall. Other required postings are also posted on the dining area wall and living room wall. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer on the left hand side of the stove. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food. MEDICATIONS: Medications are in a locked closet in the main hallway. The first aid supplies were complete, including a first aid manual. FILES: Resident and staff records are stored in the medication closet. LAUNDRY: The laundry area is located in the hallway to the right of the facility next to bedroom #1. Laundry detergent and chemicals are locked and stored inaccessible in the laundry room. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There is a gated pool that was observed to be locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south-side passageways, both gates have self-latching mechanisms. There is no front yard gate or driveway gate.There are no other structures on the property. INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 16, 2023